1
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Han S, Turkeltaub JA, Jonas D, Attwell AR, Duloy AM, Edmundowicz SA, Hammad HT, Wagh MS, Wani S, Shah RJ. The timing of recurrence after endoscopic papillectomy. Surg Endosc 2024; 38:688-696. [PMID: 38015261 DOI: 10.1007/s00464-023-10567-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Endoscopic papillectomy (EP) offers a safe and effective method for resection of ampullary adenomas. Data regarding the long-term resolution of adenoma following EP are limited. The aim of this study therefore was to examine the timing of recurrence after EP of ampullary adenomas. METHODS This was a single-center retrospective study including patients who received EP for ampullary adenomas from 8/2000 to 1/2018. Patients with confirmed complete eradication of adenoma were included in the recurrence analysis with recurrence defined as finding adenomatous histology after 1 negative surveillance endoscopy. Kaplan-Meier estimates were calculated to determine recurrence rates. RESULTS Of the 165 patients who underwent EP, 136 patients (mean age 61.9, 51.5% female) had adenomatous histology with a mean lesion size of 21.2 mm. A total of 124 (91.2%) achieved complete eradication with a follow-up of 345.8 person-years. Recurrence occurred in 20 (16.1%) patients at a mean of 3.2 (± 3) years (range 0.5-9.75 years) for a recurrence rate of 5.8 (95% CI 3.6-8.8) per 100 person-years. Nine (45%) recurrences occurred after the 1st 2 years of surveillance. Recurrence rate did not differ by baseline pathology [low-grade dysplasia: 5.2 (95% CI 3.0-9.0), high-grade dysplasia: 6.9 (95% CI 2.3-15.5), adenocarcinoma: 7.7 (95% CI 0.9-25.1)]. CONCLUSION Recurrence remains a significant concern after EP. Given the timing of recurrence, long surveillance periods may be necessary. Larger multicenter studies are needed, however, to determine appropriate surveillance intervals.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua A Turkeltaub
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniel Jonas
- Division of Gastroenterology and Nutrition, Loyola University Medicine, Chicago, IL, USA
| | - Augustin R Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anna M Duloy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hazem T Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635 Aurora Ct, Mail Stop F735, Rm. AIP 2.031, Aurora, CO, 80045, USA.
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Meunier C, Lisotti A, Gupta V, Lemaistre AI, Fumex F, Gincul R, Lefort C, Lepillez V, Bourdariat R, Napoléon B. Oral anticoagulants but not antiplatelet agents increase the risk of delayed bleeding after endoscopic papillectomy: a large study in a tertiary referral center. Surg Endosc 2022; 36:7376-7384. [PMID: 35233659 DOI: 10.1007/s00464-022-09138-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic papillectomy (EP) is an effective curative treatment in patients with ampullary adenomas. However, EP is burdened by a not-negligible risk of bleeding. The aim of this study was to determine risk factors for delayed bleeding after EP. METHODS A retrospective analysis of a prospectively-collected database was performed, retrieving all EP performed over a 20-year period. Anti-thrombotic treatments were managed according to guidelines. Delayed bleeding was defined as overt gastrointestinal bleeding or drop in haemoglobin level. Multivariate logistic regression was used to identify variables related to delayed bleeding. RESULTS Three-hundred-seven patients (48.5% male, median age 68-year-old) entered the study; of them, 51 (16.6%) received anti-thrombotic treatments. Delayed bleeding occurred in 44 (14.3%) patients. No difference was observed in patients receiving antiplatelet agents. Multivariate analysis identified oral anticoagulant agents (odd Ratio 4.37 [2.86-5.95]) and procedural bleeding (OR 2.22 [1.10-4.40]) as independently related to delayed bleeding; in patients with no procedural bleeding, oral anticoagulant agents (OR 5.63 [2.25-9.83]) and ampullary tumor size (OR 1.07 [1.01-1.13]) were independently related to delayed bleeding. Patients on anticoagulant agents presented significantly higher need for blood transfusion (16.7 vs. 1.5%); no difference in intensive care unit admission, surgery or mortality was observed. CONCLUSIONS This study demonstrates that patients on oral antiplatelet agents do not present increased risk for post-EP delayed bleeding. EP represents a valid alternative to surgery even in patients on anticoagulant agents, despite significantly increased risk of delayed bleeding. A tailored approach to those cases should be planned.
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Affiliation(s)
- Camille Meunier
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France
| | - Andrea Lisotti
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France.,Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Vikas Gupta
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France.,Gastroenterology Unit, Sunshine Coast University Hospital, Queensland, Australia
| | | | - Fabien Fumex
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France
| | - Rodica Gincul
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France
| | - Christine Lefort
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France
| | - Vincent Lepillez
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France
| | - Raphael Bourdariat
- Department of Digestive Surgery, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Bertrand Napoléon
- Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, 69008, Lyon, France.
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3
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Pradhan S, Adhikari KM, Dahal R, Pradhan S, Bhandari RS. Transduodenal surgical ampullectomy for intra-ampullary papillary tubular neoplasm (IAPN): A case report. Int J Surg Case Rep 2021; 86:106253. [PMID: 34388591 PMCID: PMC8363816 DOI: 10.1016/j.ijscr.2021.106253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/16/2021] [Accepted: 07/27/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction and importance Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy. Case presentation We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA). Clinical discussion The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis. Conclusion Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available. Intra-ampullary papillary tubular neoplasms (IAPNs) are unusual neoplasms capable of potential malignant progression. We report a rare case of IAPN which was treated through transduonal ampullectomy (TDA). TDA can be adopted as an alternative treatment approach to manage IAPNs with great efficacy and fair long-term results.
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Affiliation(s)
- Susan Pradhan
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Kathmandu, Nepal.
| | - Krishna Mohan Adhikari
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Kathmandu, Nepal
| | - Romi Dahal
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Kathmandu, Nepal
| | - Sumita Pradhan
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Kathmandu, Nepal
| | - Ramesh Singh Bhandari
- Department of GI and General Surgery, Tribhuvan University Teaching Hospital, Institute of Kathmandu, Nepal
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Khodr J, Truant S, El Amrani M. Surgical ampullectomy with resection of the common bile duct for biliary papillomatosis. J Gastrointest Surg 2021; 25:1087-1088. [PMID: 33237486 DOI: 10.1007/s11605-020-04851-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/27/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intraductal papillary neoplasm of the bile duct (IPNB) or biliary papillomatosis is a precursor lesion of papillary cholangiocarcinoma.1 IPNB is recognized as a biliary counterpart of IPMN (pancreatic intraductal papillary mucinous neoplasm). IPNB is a rare disease involving entire (diffuse type) or one part (localized type) of biliary tree. Patients without distant metastasis are considered for surgical resection. For patients with distal bile duct papillomatosis, pancreaticoduodenectomy (PD) is recommended for patients with invasive distal bile duct IPNB. PD is a high complex procedure associated with the deterioration of endocrine and exocrine functions leading to a significant impact on quality of life.2 Some authors have reported a new surgical approach leading to a complete resection of the common bile duct without pancreatectomy.3 METHODS: We report the case of a 71-year-old female presented to our department with jaundice. At endoscopic ultrasound with cholangioscopy and CT scan, 2-cm distal bile duct mass tumor with villous component was seen. All needle biopsies were benign, and no distant disease was found. According to the risk of degeneration of this tumor, a surgical resection was decided. RESULTS Intraoperative frozen section assessed the benignity of peripancreatic lymph nodes. We performed surgical ampullectomy with resection of the common bile duct. The intrapancreatic common bile duct was completely mobilized between the ampullectomy area and the upper edge of the pancreas. Frozen sections on distal and proximal margins of common bile duct were performed to discard malignancy. Finally, reconstruction consisted on the main pancreatic duct reimplantation to the duodenum and choledochoduodenostomy. The histological analysis confirmed the diagnosis of biliary papillomatosis with low-grade dysplasia. CONCLUSION This procedure allows complete resection of benign tumors with endobiliary extension and preserve intestinal continuity and pancreatic parenchyma.
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Affiliation(s)
- Justine Khodr
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Rue Michel Polonovski, 59037, Lille, France.,University of Lille, Lille, France
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Rue Michel Polonovski, 59037, Lille, France.,University of Lille, Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Lille University Hospital, Rue Michel Polonovski, 59037, Lille, France. .,University of Lille, Lille, France.
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5
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Abstract
BACKGROUND Transduodenal ampullectiomy (TDA) is a surgical local excision method that can be performed in patients with ampullary tumors, but it has not been widely used clinically. Recently, TDA is considered as a good alternative surgical technique in patients who are unable to perform the endoscopic ampullectomy (EA) or pancreaticoduodenectomy (PD) for various reasons. The purpose of this study is to evaluate the surgical outcomes of TDA and the clinicopathological significance of pathologic findings in TDA. METHODS We reviewed the medical records of 31 patients diagnosed as ampullary tumor and underwent TDA from March 2004 to December 2019 in a single center. RESULTS All 31 patients were planned to perform TDA, and 4 of them were converted to PPPD due to the marginal status results of frozen biopsy. Of the 31 patients, 19 were diagnosed with malignancy and 12 were diagnosed with benign. Of the 18 patients who were diagnosed as malignancy in final biopsy, only 9 patients (50%) were diagnosed with malignancy on the preoperative endoscopic biopsy. In 15 patients who underwent only TDA for malignancy, there was no recurrence during the follow-up period (mean: 51.1 months, range: 19-137). CONCLUSIONS In benign ampullary tumor, TDA is a choice of treatment for patients who are unsuitable for endoscopic ampullectomy. TDA may be considered as an alternative operation in highly selective patients with early ampullary cancer (Tis and T1). Further studies on consensus of TDA indication for ampullary tumor will be needed in the future.
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Affiliation(s)
- Yun Kyung Jung
- Department of Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Seung Sam Paik
- Department of Pathology, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Dongho Choi
- Department of Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyeong Geun Lee
- Department of Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea.
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6
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Nappo G, Gentile D, Galvanin J, Capretti G, Ridolfi C, Petitti T, Spaggiari P, Carrara S, Gavazzi F, Repici A, Zerbi A. Trans-duodenal ampullectomy for ampullary neoplasms: early and long-term outcomes in 36 consecutive patients. Surg Endosc 2020; 34:4358-4368. [PMID: 31646438 DOI: 10.1007/s00464-019-07206-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Trans-duodenal ampullectomy (TDA) is a surgical option for the treatment of selected ampullary neoplasms. The aim of this study was to evaluate our experience with TDA for the treatment of ampullary neoplasms, focusing on indications, technical aspects, and short- and long-term outcomes. METHODS All TDAs for ampullary neoplasms performed between January 2010 and December 2018 at our institution were retrospectively evaluated. Patients had ampullary neoplasms with low-grade dysplasia or in situ carcinoma (Tis) not suitable for an endoscopic approach, ampullary carcinoma unfit for pancreaticoduodenectomy (PD), or ampullary neuroendocrine G1-tumours. RESULTS Thirty-six patients were included in the study: 9 (25.0%) with neoplasms with low-grade dysplasia, 4 (11.1%) with G1 neuroendocrine tumours and 23 (63.9%) with Tis or invasive carcinoma. Mean operative time was 252.5 min. Overall and severe (Clavien-Dindo > IIIa) morbidity rate was 44.4% and 13.9%, respectively. No 90-day mortality was observed. At follow-up, no deaths were observed and local recurrence rate was 11.1% for patients with ampullary adenomas with low-grade dysplasia. Among four patients with neuroendocrine neoplasms, only one developed recurrence (pulmonary). Tis, T1 and T2 lesions were found in 16 (69.6%), 2 (8.7%) and 5 (21.7%) patients, respectively: recurrence occurred in 3 patients with Tis lesions (one malignant), no patients with T1 neoplasms and 2 patients with T2 lesions (3 patients had a survival of > 3 years). CONCLUSIONS TDA is a feasible and effective surgical procedure for the treatment of ampullary adenomas with low-grade dysplasia when endoscopic approach is contraindicated or has failed. For lesions with evidence of malignancy, TDA seems to be an oncological safe procedure for Tis ampullary cancer and a good palliative procedure for patients unfit for PD. Moreover, TDA may be appropriate for the treatment of G1 ampullary neuroendocrine neoplasms. A large multicentre study of TDA for early ampullary cancers is needed.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Damiano Gentile
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jacopo Galvanin
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Cristina Ridolfi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | | | - Paola Spaggiari
- Pathology Department, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Cancer Center - IRCCS, Rozzano, Milan, Italy
| | - Francesca Gavazzi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Cancer Center - IRCCS, Rozzano, Milan, Italy.,Humanitas University, Rozzano, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.,Humanitas University, Rozzano, Milan, Italy
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7
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Alali A, Espino A, Moris M, Martel M, Schwartz I, Cirocco M, Streutker C, Mosko J, Kortan P, Barkun A, May GR. Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events. J Can Assoc Gastroenterol 2019; 3:17-25. [PMID: 32010876 PMCID: PMC6985700 DOI: 10.1093/jcag/gwz007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
Background The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy. Methods Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data. Results Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically. Conclusion Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Haya Al-Habeeb Gastroenterology and Hepatology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Alberto Espino
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Gastroenterology, Pontificia Universidad Católica de Chile, Endoscopy Unit Hospital UC-Christus, Santiago, Chile
| | - Maria Moris
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Ingrid Schwartz
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cirocco
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Streutker
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Gary R May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Fernandez-Eire P, Vazquez Castelo JL, Herreros Villaraviz M, Fernandez Caamaño B, Gonzalez-Carreró J, Ausania F. Management of ampullary tumours in children: still a challenge. Ann R Coll Surg Engl 2017; 99:e139-e141. [PMID: 28462653 DOI: 10.1308/rcsann.2017.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study describes the case of the youngest patient ever reported with ampullary adenoma. The incidence of ampullary adenomas in childhood is unknown. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are used in adults to assess and treat these lesions, although there are no instruments designed specifically for use in young children. A six-year-old girl was admitted for abdominal pain, vomiting, pruritus and weight loss. Abdominal ultrasound showed biliary tree (8mm) and pancreatic duct dilatation (4mm). Magnetic resonance cholangiopancreatography and computed tomography confirmed these findings, and also showed displacement of the ampulla to the left upper quadrant. An upper endoscopy confirmed a large ampullary adenoma. A laparotomy was performed and a 5cm villous tumour arising from the ampulla was excised. The postoperative course was uneventful. The histology demonstrated adenoma of the ampulla (intestinal type) without low-grade dysplasia. all clinical and radiological parameters are normal at 20 months follow-up. We describe the case of the youngest patient ever reported with ampullary adenoma. Pancreaticoduodenectomy carries high morbidity and mortality rates, and therefore it should be avoided in absence of histologically proven malignancy. We believe that surgical ampullectomy is a safe and oncologically correct procedure until better endoscopic instruments for peadiatric use will be designed.
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Affiliation(s)
- P Fernandez-Eire
- Paediatric Surgery, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo , Spain
| | - J L Vazquez Castelo
- Pediatric Radiology, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo , Spain
| | - M Herreros Villaraviz
- Pediatric Radiology, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo , Spain
| | - B Fernandez Caamaño
- Pediatric Gastroenterology, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo , Spain
| | - J Gonzalez-Carreró
- Pathology, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo , Spain
| | - F Ausania
- HPB Surgery, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo , Spain
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9
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Mansukhani VM, Desai GS, Mouli S, Shirodkar K, Shah RC, Palepu J. Transduodenal ampullectomy for ampullary tumors. Indian J Gastroenterol 2017; 36:62-65. [PMID: 28054258 DOI: 10.1007/s12664-016-0726-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 12/08/2016] [Indexed: 02/07/2023]
Abstract
Transduodenal ampullectomy (TDA) is indicated for large ampullary tumors, for presence of dysplasia on endoscopic biopsy, for poor surgical candidates for pancreaticoduodenectomy, and in cases not indicated for endoscopic ampullectomy. Retrospective review of data from 2009 to 2015 revealed 11 patients who underwent TDA. Magnetic resonance imaging cholangiopancreatography (MRI-MRCP), contrast-enhanced computed tomography (CECT) scan, side-viewing endoscopy, and endoscopic ultrasound (EUS) were used for investigating the patients as required. Preoperative biopsy was done in all. Out of the 11 patients, only one had recurrence. Two patients had adenocarcinoma and were treated with pancreaticoduodenectomy. TDA is a safe surgical procedure for treatment of well-selected benign ampullary pathologies. It is also a treatment option for the cases of ampullary adenomas not amenable to endoscopic resection.
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Affiliation(s)
- Verushka M Mansukhani
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A 791, Bandra West, Mumbai, 400 050, India
| | - Gunjan S Desai
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A 791, Bandra West, Mumbai, 400 050, India
| | - Sasi Mouli
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A 791, Bandra West, Mumbai, 400 050, India
| | - Keval Shirodkar
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A 791, Bandra West, Mumbai, 400 050, India
| | - Rajiv C Shah
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A 791, Bandra West, Mumbai, 400 050, India
| | - Jagannath Palepu
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A 791, Bandra West, Mumbai, 400 050, India.
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10
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Guerges M, Slama E, Maskoni B, Imlay S, McKany M. Gangliocytic paraganglioma treated with ampullectomy, A case report. Ann Med Surg (Lond) 2016; 11:16-20. [PMID: 27656281 PMCID: PMC5021707 DOI: 10.1016/j.amsu.2016.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/07/2016] [Accepted: 08/08/2016] [Indexed: 12/02/2022] Open
Abstract
Background Gangliocytic paragangliomas are rare, and typically benign neuroendocrine neoplasms usually found in the second portion of the duodenum. Though recurrence is rare, metastatic cases have been noted. A standardized treatment has not been determined. An endoscopic resection can be carried out, unless metastasis has been noted. We present the case of a patient who underwent an ampullectomy, with successful removal of the tumor, and no recurrence on follow-up. Case summary We present a case involving a 58-year-old gentleman, who presented with dysphagia, and ultimately diagnosed with a periampullary mass proven to be a gangliocytic paraganglioma. The tumor was resected in-toto via an ampullectomy. The patient had no recurrence after twenty-one months. Conclusion In conclusion, we present the case of an incidental gangliocytic paraganglioma occurring in the periampullary region of the patient. Ampullectomy was carried out and to date the patient has had no recurrence. Rarity of this tumor, along with treatment choice, makes it especially worthy of notability. Gangliocytic paraganglioma are rare neuroendocrine tumors. Gangliocytic paragangliomas are typically found within the duodenum. These tumors are commonly benign, but have malignant potential. There is no defined standard of treatment for gangliocytic paraganglioma.
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Affiliation(s)
- Mina Guerges
- Corresponding author. Department of Surgery, St. Joseph Mercy Oakland Hospital, USA. Tel.: 248 858 3000.Department of SurgerySt. Joseph Mercy Oakland HospitalUSA
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Panzeri F, Crippa S, Castelli P, Aleotti F, Pucci A, Partelli S, Zamboni G, Falconi M. Management of ampullary neoplasms: A tailored approach between endoscopy and surgery. World J Gastroenterol 2015; 21:7970-7987. [PMID: 26185369 PMCID: PMC4499340 DOI: 10.3748/wjg.v21.i26.7970] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/27/2015] [Accepted: 05/04/2015] [Indexed: 02/07/2023] Open
Abstract
Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.
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Yang D, Reinhard MK, Wagh MS. Feasibility and safety of endoscopic cryoablation at the duodenal papilla: Porcine model. World J Gastrointest Endosc 2015; 7:728-735. [PMID: 26140100 PMCID: PMC4482832 DOI: 10.4253/wjge.v7.i7.728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/27/2015] [Accepted: 04/02/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the feasibility and safety of liquid nitrogen spray cryoablation at the duodenal papilla in a porcine model.
METHODS: This prospective study protocol was approved by the University of Florida Institutional Animal Care and Use Committee. Six pigs underwent liquid nitrogen spray cryotherapy at the duodenal papilla. Freeze time of 20-s was applied per cycle (4 cycles/session). Survival animals (n = 4) were monitored for adverse events. Hemoglobin, white blood count, liver tests, and lipase were obtained at baseline and post-treatment. EGD was performed on day#7 to evaluate the papilla and for histology. All animals were euthanized and necropsy was performed at the end of the one-week survival period. Feasibility was defined as successful placement of the decompression tube in the duodenum, followed by delivery of spray cryotherapy to the duodenal papilla. Safety was determined by monitoring post-treatment blood tests and clinical course. Treatment effect was defined as endoscopic and histologic changes after cryotherapy. This was established by comparing endoscopic and histologic findings from mucosal biopsies prior to cryotherapy and on post-operative day (POD)#7. Full-thickness specimen was obtained post-mortem to assess depth of injury.
RESULTS: Spray cryotherapy was feasible and successfully performed in all 6/6 (100%) animals. Cryospray with liquid nitrogen (four 20-s freeze-thaw cycles) at the duodenal papilla resulted in white frost formation at and around the target region. The mean procedural time was 54.5 min (range 50-58 min). All six animals studied had stable blood pressure, heart rate, and pulse oximetry measurements during the procedure. There were no significant intra-procedural adverse events. There were no significant differences in hemoglobin, white cell count, liver tests or lipase from baseline to post-cryotherapy. Survival animals were monitored daily post-operatively without any clinical ill effects from the cryotherapy. There was no bleeding, infection, or perforation on necropsy. Endoscopic on POD#7 showed edema and ulceration at the duodenal papilla. On histology, there was loss of crypt architecture with moderate to severe necrosis and acute mixed inflammatory infiltration in each specimen following cryotherapy. The extent of cryogen-induced tissue necrosis (depth of injury) was limited to the mucosa on full-thickness specimen evaluation.
CONCLUSION: Endoscopic liquid nitrogen spray cryotherapy is feasible and safe for ablation at the duodenal papilla in a porcine model.
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Tsuji S, Itoi T, Sofuni A, Mukai S, Tonozuka R, Moriyasu F. Tips and tricks in endoscopic papillectomy of ampullary tumors: single-center experience with large case series (with videos). J Hepatobiliary Pancreat Sci 2015; 22:E22-7. [PMID: 25688984 DOI: 10.1002/jhbp.207] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/09/2014] [Indexed: 12/18/2022]
Abstract
Endoscopic papillectomy (EP) has been recognized as a safe and reliable treatment for ampullary adenomas. In this article, we describe important tips and tricks in EP of ampullary tumors on the basis of our large case series outcome. Between May 1999 and April 2014, 115 patients underwent EP at Tokyo Medical University hospital. The mean tumor diameter was 16.2 (6-35) mm. The final pathological diagnoses were adenoma, cancer in adenoma, cancer, and hyperplasia in 85, 13, 10, and seven patients, respectively. "En bloc" or "piecemeal" EP was performed with a polypectomy snare forceps using "Endocut® mode". Prophylactic pancreatic duct stents were placed after EP. Consequently, a single treatment session was possible in 93 (80.9%) patients. Additional treatment was required in the remaining 22 (19.1%) patients. For these 22 patients, the postresection pathological diagnoses were adenoma in 15 patients and cancer in seven patients. Two patients with cancer and venous permeation required surgical operation. The final complete resection rate was 98.2%. Several complications observed included pancreatitis (10.4%), bleeding (18.2%), perforation (2.6%), cholangitis (1.7%), and papillary stenosis (4.3%). One patient died of procedure-related complications. In conclusion, endoscopic papillectomy showed a high technical success rate. However, possible complications and occasional fatal complications should be considered when using EP.
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Affiliation(s)
- Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy. World J Gastrointest Endosc 2011; 3:241-7. [PMID: 22195233 PMCID: PMC3244941 DOI: 10.4253/wjge.v3.i12.241] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/21/2011] [Accepted: 08/28/2011] [Indexed: 02/05/2023] Open
Abstract
Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic. It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance. Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy. Those that are used most commonly include computed tomography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography. In recent years, endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas. Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma. This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.
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Affiliation(s)
- Payam Chini
- Payam Chini, Peter V Draganov, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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Abstract
AIM: To investigate the endoscopic ampullectomy practices of expert biliary endoscopists.
METHODS: An anonymous survey was mailed to 79 expert biliary endoscopists to assess ampullectomy practices.
RESULTS: Forty six (58%) biliary endoscopists returned the questionnaire. Of these, 63% were in academia and in practice for an average of 16.4 years (± 8.6). Endoscopists performed an average of 1.1 (± 0.8) ampullectomies per month. Prior to ampullectomy, endoscopic ultrasound was “always” utilized by 67% of respondents vs“sometimes” in 31% of respondents. Empiric biliary sphincterotomy was not utilized uniformly, only 26% “always” and 37% “sometimes” performed it prior to resection. Fifty three percent reported “never” performing empiric pancreatic sphincterotomy prior to ampullectomy. Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy (OR = 10.9; P = 0.09). Participants overwhelmingly favored “always” placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection (23%). Argon plasma coagulation was the favored adjunct modality (83%) for removal of residual adenomatous tissue. Practitioners uniformly (100%) preferred follow-up examination to be within 6 mo post-ampullectomy.
CONCLUSION: Among biliary experts, there is less variation in ampullectomy practices than is reflected in the literature.
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Abstract
Ampullary carcinoid is a rare tumor that can present with gastrointestinal bleeding, obstructive jaundice or pancreatitis. Some of these tumors are associated with Von Recklinghausen disease. The usual surgical options are a biliary-enteric anastomosis, Whipple procedure or rarely a local resection. The mean survival does not appear to be much different after a pancreaticoduodenectomy versus local surgical excision. We report a very rare case of a non-metastatic ampullary carcinoid causing upper gastrointestinal bleeding, which was managed by endoscopic ampullectomy.
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Affiliation(s)
- Nooman Gilani
- Department of Medicine and Research, Gastroenterology Section, Carl. T. Hayden Veterans Administration Medical Center, Phoenix, AZ 85012, USA.
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